The Workers Compensation Attorney Group is here to fight for the benefits that you are lawfully entitled to if you are injured at work. We understand the feeling of worry that can overwhelm individuals trying to cope with workers’ compensation cases and the complicated legal system. We are experienced, aggressive, ethical, and we will help you each step of the way as you fight for your rights. Read on to understand the steps you should take if your workers' compensation is denied.
Common Reasons Why a Workers’ Compensation Claim is Denied
When your claim is denied, you will receive a denial letter explaining the reasons for the denial, and the time you have to file an appeal. Before you appeal this decision, it is essential to find out the reason why your claim was denied in the first place. The reasons may include:
- Your injury happened away from the job site
You are eligible to workers' compensation benefits if your damage occurs while performing your job duties. For example, if you work in a hospital as a janitor and you slip, fall, and break your hand while cleaning, you are owed compensation. On the other hand, if you were commuting to the hospital and you got injured, there is a low likelihood of you having the right to make a claim. However, it is not apparent around this rule in case you got injured away from your job site, but you were at a work event or retreat.
It is essential to understand that, the insurance companies and even at times your employer, may do anything possible to try and ascertain that your injury was incurred while you were away from work, also if you know you were working. It can be very tough to challenge such a decision, especially if there is no CCTV footage or witnesses to confirm your claims.
- Failure to inform your employer of your injury within the stipulated time
Time is of the essence when it comes to matters concerning workers' compensation claim process. It is essential to inform your employer about your injury as soon as possible after you are injured. Failure to report your damage as quickly as possible may result in several outcomes. They are:
- Your employer will be unable to investigate the accident, which is crucial for the victory of your claim.
- The insurance company and your employer could argue that you were not at work when you were hurt, which was the reason you couldn’t report the injury sooner.
- The insurance company can try to argue that the damage was due to an existing problem that happened while off duty but not due to your job duties.
The sooner you tell your employer about your injury, the better for you. Waiting a little bit longer might cost you of your entitled benefits.
- A professional medical provider did not treat you
Under the workers' compensation system, the insurance company and your employer are entitled to provide you with a list of approved doctors you can consult for treatment. In some cases, it may be a disadvantage because the doctors may be working with your employer and the insurance company to lower your benefits by downplaying your injuries. Therefore, it is essential to see an approved medical provider as it makes the process of compensation claim smoother.
- You were under the influence of alcohol or drugs
When you go to seek medical attention for a work injury, your employer has a right to ask the doctor to test you for drugs or alcohol. If tests show that you were intoxicated when the accident happened, your claim will be denied because drugs or alcohol was involved in your accident.
- Your claim was filed past the deadline
When it comes to filing your workers’ compensation claim, you should cautiously consider time limits and deadlines. If you fail to file your claim on time, you are giving the insurance company and your employer the basis to deny your claim.
- You never visited any doctor for treatment
You can get small bruises and scratches at work which might not require a doctor's attention. If you, however, contemplate on claiming benefits, you will need a copy of your health record from an approved doctor to justify the claim. If you try to file a workers’ compensation claim later on without a medical history to support it, the insurance company can easily say you were claiming benefits for fake injuries.
If you were injured at work and ignored seeing a doctor, then file a claim after you get fired, the insurance company can argue that revenge on your former employer pushed you to file a claim. It is imperative to see a doctor if you get injured at work as it gives your request a higher chance of succeeding.
- Your injury was the result of a practical joke
Sometimes what seems like fun and games can end up being disastrous. If you initiated roughhousing at work and got hurt in the process, your injuries are unlikely to be covered since, in the eyes of the law, you were not working. Similarly, an injury sustained as a result of a fight at work is not eligible for compensation.
- Your employer disagrees with your claim
The fear that your employer's cost of workers' compensation coverage will increase if there is a claim on their policy might cause them to disagree with your claim. To fight this, they could argue that you were not injured at work or the details of the case are false. If there were no witnesses or CCTV footage to back your claim, their point could be considered authentic.
Therefore, it is safe to inform your co-workers and employer when you suffer injuries, and no one saw the incident. It is also crucial to contact your attorney early enough to enable them to plan how to handle your case even if your employer is fighting it.
- Your injury existed before the work-related injury
If you had an injury before starting the job, which then included activities that worsened the said injury, you are eligible for workers’ compensation benefits. Your employer and the insurance company will argue that your injury was a prior existing injury and was not affected by the work to see your claim rejected in order to fight the claim.
Due to the complexity of workers’ compensation claims, some workers give up on their benefits because they don’t know what steps to take.
Workers’ Compensation Appeal Process
It would be best if you did not give up when your workers' compensation claim is denied, or you don't agree with the insurance company about your case. You have the right to appeal. The appeal process involves a lot of paperwork and several steps.
Step1: Application for Adjudication of Claim
An application for adjudication of claim form is used to begin a formal proceeding against the employer with the Workers' Compensation Appeal Board (WCAB) in a workers' compensation case. The application for adjudication of a claim provides information about the incident to every party involved in the claim: the worker’s injuries, the venue for the case (employee’s resident county), the county where the injury occurred and the place of business of the worker’s lawyer.
Once the Workers' Compensation Appeal Board is presented with the Application for Adjudication of claim form, they will give it a case number. They will also be granted the power to resolve disputes on the worker's claim. The board will review the form together with the supporting documents like medical records. The form must be filed within one (1) year after:
- the date of injury
- the day your temporary disability benefits end
- the last day you received medical benefits from your employer
In the case that an employee develops new disabilities after the injury, they have five (5) years from the date of injury to apply.
Step 2: Declaration of Readiness to Proceed (DOR)
A DOR form is used in workers’ compensation claims to show the intention of the injured worker’s readiness to carry on with the compensation case and appeal for a conference with the local Workers’ Compensation Appeals Board (WCAB) office. The aim of filing the DOR form is to allow the contended work compensation claims to be reviewed and heard by the Workers’ Compensation Appeal Board judge. A Declaration of Readiness to Proceed form can be used to settle many disputes involving compensation rates, permanent disability ratings, vocational rehabilitation, self-procured medical treatment, temporary disability benefits, and penalties.
Once the form is submitted, a conference will be scheduled, and you will receive a notification of your conference date via email. You may need to complete and file letters to the insurance company concerning the disputed matters, medical reports along with the Declaration of Readiness to Proceed form.
Step 3: Settlement Conference
In California, the settlement conference is mandatory. It is a workers’ compensation hearing that allows the insurance company and the injured worker to talk over disputed issues and if crucial, set the case for trial. During the settlement conference, the parties fill out a joint statement termed as Pretrial Conference Statement that records agreed and disagreed issues. The judge uses this statement to guide the trial.
The most common issues in the settlement conference concern:
- if the employee should receive permanent disability and the amount
- Whether the injured employee qualifies for temporary disability benefits
- Which body parts are damaged?
- If there is a work-related injury
Step 4: Workers’ Compensation Hearing
A workers’ compensation hearing is the same as a trial. Hearings are held in case the involved parties fail to settle their differences. During this hearing, both parties have a chance to present evidence, make a legal argument about the case, and have testimonies from witnesses. Generally, there should be no presentation of new evidence that was not shared during the settlement conference.
At the commencement of the hearing, you and the insurance company will hand over the documents to the judge for review. The documents include:
- Report from the doctor who treated you,
- Unpaid medical bills,
- Employment records, and
- Evidence of your lost wages.
At the hearing, you will usually testify, and typically your testimony will include:
- How you were injured,
- Your normal job responsibilities,
- Your symptoms and restrictions on what you can do due to the injury, and
- Any attempts to go back to work.
During the hearing, it is essential to be polite, honest, and respectful at all times; otherwise, you may hurt your opportunity of succeeding in your claim. You should be appropriately dressed in clean clothes and arrive on time for all meetings.
Step 5: Petition for Reconsideration
After the workers’ comp hearing, you will receive the judge’s decision either through the mail or in person. If you are not satisfied with the award, you will file a Petition for Reconsideration with the local district office where your case was initially heard. Under California Labor Code Section 5903, you have exclusively twenty (20) days from the date you received your award from your local district office to appeal it. However, if you received the judge’s decision through the mail rather than hand delivery, you have twenty-five (25) days from the date the decision was made.
Some of the reasons that can cause you to file a Petition for Reconsideration are: (1) If you have discovered new evidence, (2) you are convinced that the evidence in your case doesn’t back the judge's award, or (3), there was a fraud by the other side. The reasons usually are listed on the form. Be sure to include all the issues you want the appeals board to look into, including why you disagree with the judge’s decision.
Once you file the Petition for Reconsideration, the WCAB has sixty (60) days to accept it or deny it. If the appeals board approves your petition for review, the board will amend the original award. You will know the petition is rejected if the WCAB doesn't act within the sixty (60) days. The appeals board decides the appeal without another hearing unless there is new evidence where they schedule for another hearing. Once the appeals board has decided on the petition, they will mail you their decision.
Step 6: Judicial Appeal
If you are not happy with the WCAB’s decision in the initial appeal, you have the right to file a petition for 'writ of review' with the district appellate court in your region. However, there is nothing much the court of appeal can do to change the decision by WCAB. Their main work is to establish whether the decision made by WCAB is in consideration of the facts presented. It is rare that the court of appeal can change the WCAB’s decision.
All the issues in the writ must be the same as those in the Petition for Reconsideration. A writ must also be filed within forty-five (45) days from the date of the award by a WCAB judge. If the court of appeal denies your claim, you can petition with the supreme court.
Workers’ Compensation Claim After Termination
Workers’ compensation claims usually address needs in circumstances where you get injured and file the claim while still employed. Sometimes an employee may be injured and decide the injury is minor, thereby fail to inform the employer. After a while, the employee may be laid off, and then the damage may develop into a severe problem. Nevertheless, it is possible for a worker to file their workers’ compensation claim after termination provided a few requirements are met.
In California, the worker is required to prove that the illness or injury is job-related, which can be very difficult if much time has passed before they file a claim. The law also requires that the worker filing the claim meets one of the following conditions.
- The employee must have informed the former employer about the injury before the termination notice,
- The worker's medical records must show evidence of the damage occurring before notice of termination or,
- The injury occurred after the termination date, but before the termination was concluded.
Each post-termination workers' compensation claim presents its contingencies and complications. Therefore, it is essential to seek the guidance of an experienced attorney who is conversant with workers' compensation claim matters.
California’s Workers’ Compensation Laws
- Employers are required by law to give workers’ compensation to all workers, with few exceptions. (sec 3351, et seq. 3700)
- Within one (1) day of the injury notice, the employer must give the injured employee a claim form and authorize treatment (up to $10,000); if the claim is not rejected within ninety (90) days, it is presumed the injury is covered (sec.5402)
- The employee should file a claim within one (1) year since the date of injury (sec.5405)
- The employer must give the injured worker a claim form within one (1) day of receiving notice of injury. (sec. 5401)
- The employee should give their employer a written notice of the work-related injury within thirty (30) days.
Types of benefits
- Medical care; medical equipment, hospital services, doctor visits, lab tests, and x-rays. (sec 4600)
- Temporary disability payments; payment for wages lost during the recovery process. (usually calculated at two-thirds of your pre-tax salary and not for beyond 104 weeks) (sec.4650, et seq.)
- Permanent disability payments; payments you receive if you don’t recover entirely and the injury renders you permanently disabled physically or mentally. The amount and the period of benefits are determined by the degree of your disability. (sec, 4658)
- Retraining: these are payments made to cater for your retraining if you are incapable of returning to your previous employment. (sec, 4658.7)
- Death benefits; payments made to your dependents or next of kin if you succumb to a work-related injury or illness. (sec, 4700)
Secrets Insurance Companies Don’t Tell You
- Insurance companies push you to see their doctor
The most significant benefit under workers' comp is access to medical care. You have the right to access unlimited treatment for your work-related injury. Medical treatment can include prescription medication, wheelchairs, dental care, artificial limbs, eyeglasses, hearing aids, surgery, and other devices vital to cure or relieve the aftermath of your work-related injury.
If your workers’ compensation benefits are ever denied, you need a doctor who can back you. If you are receiving treatment from a doctor recommended by the insurance company, be on the lookout because of a conflict of interest. You can find a good doctor by consulting with your family and friends and give the name and address of the doctor you prefer to the insurance company.
- Insurance companies are watching you
Insurance companies will try to find any proof that your claim is not genuine. They hire private investigators to follow and record activities of people who claim workers’ benefits. The investigators scour social media and even speak to your neighbors behind your back, looking for proof against you.
- Your wage loss benefits are repeatedly paid at the wrong rate
Insurance companies make mistakes that are meant to oppress you. Some companies fail to include premium pay, bonus payments, and overtime in your weekly wage calculation or even use the incorrect tax filing status.
- Insurance companies lie about the available benefits
Insurance companies desire to save money on workers’ compensation claims. Consequently, you are not told about available benefits under the law. The insurance company must pay the cost of attendants ranging from nurses and other skilled individuals who help the injured worker in tasks such as bathing and mobility. If Your family member is offering assistance, they should be paid by the workers’ compensation at the same hourly rate as a professional.
- It is standard practice for insurance companies to argue against specific work injuries
Insurance companies must argue about certain work injuries because they are considered natural but not work-related, i.e., claims for arthritis issues.
Find a Workers’ Compensation Attorney Near Me
In the unfortunate event where you are injured while at work, and your compensation claim is denied, you can despair and feel discouraged due to the complexity of workers' compensation cases. If you are in Long Beach, California, and looking for a workers’ compensation attorney to help out on your workers’ compensation claim, get in touch with The Workers Compensation Attorney Group by calling our Long Beach workers comp attorney at 714-716-5933. We are here to evaluate your claim and help you fight for your benefits.